In Your Own Words

We did a poll concerning the COVID-19 pandemic to give you an opportunity to tell us how this worldwide virus has impacted you. Your answers revealed some interesting information on how older Americans are weathering this unprecedented health emergency.

The first question was:

Concerning the impact of COVID-19 on your physical health – check all that apply.

Below are the choices and the percentage each choice was selected:

Has it been more difficult to get your medicine? 27.1%

Is it harder to see a doctor? 39.6%

Have you had trouble receiving home health? 8.3%

Other 25%

As you can see the response selected more often was the difficulty in seeing your doctor. You can understand that the fear of going out to a doctor’s appointment, especially for non-emergency issues, kept many people from venturing out to the doctor’s office. I wonder how many cancer screenings, colonoscopies, blood tests, physicals, etc. were missed and what price seniors will pay for this inability to get both preventative care as well as needed periodic care for existing conditions. I’m afraid that the effects of the pandemic on the health of seniors will be long term and costly.

The second most selected choice was difficulty in getting medicine. One of the fears providers had, with the strict quarantining recommendations, especially for older people, was – it would hinder seniors from getting their prescription medications. It was also worrisome that the supply chain for medications would be interrupted causing shortages. The quick response to expand the number of pills per prescription, the reduction or elimination of out-of-pocket costs and the ingenuity in maintaining adequate supplies all helped to ensure we were able to continue to get our needed prescriptions.

The third most selected choice was “other”. This pandemic affected each of us in a very personal way. We all are different and it affected us in different ways but there is no doubt it is affecting us all significantly.

Only 8.3% said it was difficult getting home health care. I hope this continues to be the case.

The second question was:

Concerning the impact of COVID-19 on your emotional health – What worries you the most?

Below are the choices and the percentage each choice was selected:

Becoming sick with COVID-19 21.6%

Your family members becoming ill with COVID-19 27%

Loss of retirement 5.4%

Loneliness 5.4%

Family members losing employment 18.9%

Access to healthcare 13.5%

Other 8.1%

The top two choices were fear of you or your family getting sick with the virus. As it seems is always the case we had more fear that one of our family members would get the virus rather than ourselves. That was also the case with worrying about our retirement or our family’s employment. We were much more worried about our family losing employment than we were about losing our retirement. It is interesting that only 5.4% chose loneliness as a problem. I think we might be seeing the reduction in restrictions as a light at the end of the tunnel and seeing hope that we can visit our families. It might also be that technology has helped. There our substantially more older Americans that know how to use Zoom than before the pandemic.

The third question was:

Who do you turn to for reliable COVID-19 information?

Below are the choices and the percentage each choice was selected:

TV news 24.3%

The daily Coronavirus Task Force briefings 27%

Internet 21.6%

Radio 2.7%

Newspaper 2.7%

Other 21.6%

The daily Coronavirus Task Force briefings was the top choice. I know I appreciated hearing Dr. Fauci’s insights and developed a trust for his opinions. We still go to the TV for our news and the daily briefing, the TV is our window on the world. The internet is moving up the ranks and the distinction between the “TV” and the “internet” is blurring. We are nearing the world where our internet is the conduit to news, radio, newspaper and any other information we seek. I do wonder where the 21.6% who selected other got their information? I suspect it is friends or family who visit with us and talk about the pandemic.

The fourth question asked:

In their response to COVID-19, do you think healthcare industries (hospitals, drug and device manufacturers, insurers) have:

The choices and the percentage selected are:

Performed better than expected 54.1%

Performed as expected 27%

Performed worse than expected 18.9%

It might have been a little difficult to evaluate the healthcare industries’ performance given none of us had ever experienced a pandemic like this. Given that, over half of us said they did better than expected and only 19% said they did worse than expected. I think three things impressed us:

the bravery of the healthcare workers as they exposed themselves to danger as they cared for us

the quick reaction of our insurance providers to cut our out-of-pocket expenses so that cost did not hinder our access to care and medicines (I just a received a card from my Medicare Advantage insurer that waived all out-of-pocket costs for primary care visits, outpatient behavioral health visits and telehealth visits)

The willingness of pharmaceutical manufacturers to band together and spend millions of dollars to look for medicines that will reduce the severity of the COVID-19 and to produce an effective vaccine.

Sometimes adversity brings out the best in us.

The final question asked:

In their response to COVID-19, do you think the federal government (Congress and the Administration) has:

The choices and the percentage selected are:

Performed better than expected 18.9%

Performed as expected 18.9%

Performed worse than expected 62.2%

It seems we don’t think our government responded very well to this pandemic. We did have other countries’ response that we could use as we compared the effectiveness of our country’s response. There is still a lot we don’t know about what actually happened. Some countries that started out with lower infections were later inundated. State governors responded very differently and the resulting number of COVID-19 infections varied widely. As time goes on we’ll know more about what methods worked and what didn’t. We’ll also know what information our government had and when they had it and how they responded to it. But right now, there is no doubt that we aren’t happy with the government’s response.

We’re glad you chose to speak up and participate in our poll. We will continue to do surveys and polls to give you a chance to speak out. In the meantime, stay safe and have joy.

I hope this communication finds you safe and finding ways to have joy in these trying times. I have faith that we will emerge stronger and smarter from this experience.

First of all, I want to thank everyone who has participated in our survey and encourage anyone who hasn’t to click here and give us your input. The survey asks about your experiences with the COVID-19 pandemic, your health, your healthcare, how the government and drug manufacturers have performed so far and how you get your information about the pandemic. It is important for you to speak out about these important health issues. Those in Washington, that have such an impact on our lives in these stressful times, need to know how you feel about these issues. Please participate.

Second, I want to talk about importation. This is an issue that I’ve talked about before. It has been trumpeted by Washington at different times over the years as a way to lower costs. The importation of prescription drugs has some basic flaws:

It lacks the basic safeguards to guarantee the safety of the medicine

The approach is resisted, or is outright rejected, by the very countries who would be counted on to support this approach

The Congressional Budget Office (CBO) has calculated that importation would result in minimal savings, if any at all

I can’t help but think that the COVID-19 pandemic has highlighted another flaw, our reliance on other countries for our medicine. I’m not talking about the raw materials or manufacturing that are supplied or accomplished by foreign countries and certified by the FDA. I’m talking about legislation that circumnavigates these established, inspected and approved supply lines and opens up pathways for counterfeit drugs. We see today countries arguing about who would get COVID-19 vaccines or medicine first, deals being made between countries that might ignore the priority of getting medicines or vaccines to those who need it most. It highlights another reason that importation legislation is not the solution. When push comes to shove a foreign country’s priorities will come before ours and any agreement that is not based on economics and competition will be driven by political priorities that will not be to the safety and benefit of the patient.

As I have said before, as the elections get closer, the politicians will begin to focus on schemes to get elected. Importation may again be presented as a solution to drug prices. We all need to understand the real dangers of this flawed solution.

I want to thank everyone who joined our Seniors Speak Out
tele town hall yesterday. We discussed the impact on senior’s healthcare that
the COVID-19 pandemic has had, and could have, in the future. We also discussed
what might happen with healthcare issues and legislation in this election year.
I appreciated the questions, both written and expressed during the tele town
hall. In response to one of the questions I am including the link to the IRS’
Get My Payment web site where you can check on the status of your stimulus
check. Just click here
to get to the site.

We also announced the broadening outreach of the new Seniors
Speak Out. The use of polls and surveys, of webinars and tele town halls, and,
when appropriate, visits to expos, seminars and anywhere mature Americans
gather. Our goal is to find out how seniors truly feel about their healthcare
and what their stance is on the issues that affect their lives. We are looking
forward to this journey as we face this trying but important year.

Our first poll is ready on our web site – just click here
to take the poll and participate in this process of speaking out.

I look forward to working with you as we seek to speak out
and be heard.

Here we are, hunkered down and wondering when, or if, we’ll be back to normal. It is a strange juxtaposition we are involved in . . . a national disaster that, in the past, has brought us together now forces us apart. I hate that we can’t gather our families together to weather this storm, but it is best, especially for us older folk, to stay isolated and wait for the “all clear” message. I’ve included some links below that will give you access to health and financial information concerning the COVID-19 pandemic. Here are a few updates on how our government is working to help out and guide us.

The 2 trillion-dollar stimulus legislation has been signed
by the President. It contains a multitude of economic fixes. I will highlight a
few of what is in the bill and a few things that were left out:

The bill allows us to have the medicine we need while we are quarantined (see my last blog) by allowing doctors to prescribe up to 90-day prescriptions without any restrictions by pharmacies or insurance providers.

The bill also includes provisions to expand telehealth, a great idea to get help from a health care provider without leaving the safety of your house.

Any costs related to getting tested for COVID-19 will be done with no costs to the patient.

We will be getting as much as $1,200 in a one-time check. It will be based on our 2018 Adjusted Gross Income. If you made too much money in 2018 your check could be reduced or eliminated.

Some changes affect your retirement funds. Talk to your financial advisor to see if any of the changes will help you.

One thing that wasn’t included in the bill was the ability
to have some Medicare Part B drugs, primarily those that were injectable or infused,
be provided in the home if the patient and physician think that’s the best
option. It would have allowed much safer access to these life altering and life
saving drugs. Many organizations fought for this change, but it wasn’t
included. We hope that some later legislation will recognize the importance of
this provision.

Another change that might help is the IRS has delayed when
you need to file your 2019 taxes. Both the filing date and, more importantly,
when any taxes you might owe are due has been extended to July 15th.
Click on the IRS link below to get more information.

While the just passed legislation dealt with the immediate
financial problems of those that were suddenly laid off and small and large
businesses that were impacted by the pandemic, I want to remind our government
that many seniors will also be affected financially. As we saw in the great
recession, many older Americans found that they were the ones that rescued
their children by letting them move back in with them or offering free childcare
as their kids weathered the recession. We all know that we will do anything for
our kids, but we’re older now and our retirement funds have been decimated.
I’ll work to keep Washington apprised as this pandemic and its effects on the
economy plays out, making sure they know how it affects the seniors in our
country.

In the meantime, stay safe and stay involved, our country
needs your steady spirit as we work to weather this storm.

Thair

HELPFUL LINKS

SENIORS

The CDC has guidance for older Americans on COVID-19 which can be found here.

For questions about receiving Social Security benefits during the COVID-19 national emergency, visit the SSA’s updates and frequently asked questions page here. If you need to get in touch with your local Social Security Office, use the office locator here to find their phone number.

Mental
Health and Other Wellness Resources

The National Alliance on Mental Illness (NAMI) has a resource guide on dealing with anxiety related to COVID-19 and some frequently asked questions, which can be found here.

The National Suicide Prevention Lifeline is free, confidential, and available 24/7 at 800-273-8255.

The National Domestic Violence Hotline has resources and recommendations for staying safe during COVID-19, which can be found here. If you or a friend needs help, call the hotline at 1-800-799-SAFE(7233).

VETERANS

Updated information on COVID-19 from the Department of Veterans Affairs can be found here.

What should veterans do if they think they have COVID-19?

Before visiting local VA medical facilities, community providers, urgent care centers, or emergency departments in their communities, veterans experiencing COVID-19 symptoms—such as fever, cough, and shortness of breath—are encouraged to call their VA medical facility or call MyVA311 (844-698-2311, press #3 to be connected). Veterans can also send secure messages to their health care providers via MyhealtheVet, VA’s online patient portal. VA clinicians will evaluate veterans’ symptoms and direct them to the most appropriate providers for further evaluation and treatment. This may include referral to state or local health departments for COVID-19 testing.

What about routine appointments and previously scheduled
procedures?

VA is encouraging all veterans to call their VA facility before seeking any care—even previously scheduled medical visits, mental health appointments, or surgical procedures. Veterans can also send secure messages to their health care providers via MyhealtheVet and find out whether they should still come in for their scheduled appointments. VA providers may arrange to convert appointments to video visits, where possible.

Can visitors still access VA medical facilities?

Many
VA medical facilities have cancelled public events for the time being, and VA
is urging all visitors who do not feel well to postpone their visits to local
VA medical facilities. Facilities have also been directed to limit the number
of entrances through which visitors can enter. Upon arrival, all patients,
visitors, and employees will be screened for COVID-19 symptoms and possible
exposure.

IRS

The IRS has established an updated resource section on steps to help taxpayers, businesses, and others affected by the coronavirus, which can be found here.

A few days ago, I received information from Healthcare.gov, a website created by the part of our government that oversees Medicare, concerning the Coronavirus. It offered the following guidelines to help us as we combat this serious health risk:

To prevent
the spread of this illness or other illnesses, including the flu:

Wash your hands often with soap and water,

Cover your mouth and nose when you cough or
sneeze,

Stay home when you’re sick, and

See your doctor if you think you’re ill.

Good
information but I think they missed something that is key in this battle . . .
ensuring each of us have ample medication or required medical supplies to last
through a 14-day quarantine period or weeks longer if required.

Many of
us take daily medicine or require medical supplies that enable us to live
normal lives and, in some cases, keeps us alive. If we are quarantined
because we contract the virus or to keep us from coming in contact with someone
who has, we quite possibly won’t have the chance to renew our prescription or
obtain enough medical supplies to last through the quarantine period or weeks
longer if required. Now is the time to think about this possibility and
take the needed steps to be prepared.

Determine
what medicine and medical supplies you may need and contact your doctor or
pharmacist as well your medical supplies company to obtain the medicine and
supplies you need to make it through at least a quarantine period and even a
few weeks longer. If you are a caregiver take the needed steps to protect
those you care for.

These are
strange times and we need to take care of ourselves and our loved ones by being
prepared.

As you might notice the name of this blog is, “Seniors Speak Out”. That means that somehow, I need to tap into what older Americans find important. I can’t do that unless I find a way to get out and actually talk with those of us who can be classified as seniors . . . and that’s exactly what I’m going to do.

The idea of a listening tour is not new, I did one a few years ago when I ran a senior advocacy organization. I found it was a great way to really understand how seniors felt. I was somewhat limited in how much of the nation I could get to on that listening tour, but I’m not limited this time. I am committed to getting to all corners of our nation. I know that there are state and regional differences in healthcare, and it will be important to listen to, and convey, those differences. I will focus on getting in front of small groups at assisted living and senior centers, to get on radio programs to invite comments, to go to senior fairs and expos and to go to important senior conferences. My goal will be to find out what is important to you, what keeps you up at night, how you feel about the proposed changes to health care and what solutions you might have. I then will assemble your comments, views and solutions into simple and common-sense statements that I can deliver to Capitol hill. Something that will convey to them how seniors really feel.

Just recently, I had a chance to speak to a group in Virginia. We spent about an hour and a half discussing healthcare. One of the things they brought up was the difference in the price of their prescription drugs when they go to the pharmacist and use their insurance as compared to when they use a discount card and finally when they go someplace else, like Costco, and pay cash. The question was asked, “why does the cost to the patient differ”. We had quite a discussion and I won’t go into it here, but it is the type of discussion that America needs and one that the people in Washington need to hear about.

I would like your help. If you would like to have a chance to tell me and your members of Congress how you feel about your healthcare please click here and tell me when and where. I might not be able to accommodate all the requests, but I’ll do my best.

This blog is about you, the patient, and I’m looking forward to getting to know exactly how you feel.

When the Affordable Care Act (also known as Obamacare) was
passed into law there were those who liked it and those who didn’t. There were,
however, some parts of the law that people on both sides liked. One of those
parts that found a large following of fans was the creation of the Center for
Medicare and Medicaid Innovation (CMMI).

CMMI was set up to be a petri dish for trying out new and
more efficient ways to administer health care. To do this, CMMI was allowed to
be free of many government regulations, use ideas from many sources, sign up
providers who wanted to try out these new approaches and carefully analyze the
results. What a great idea . . . rather than the government overhauling a huge
part of a health care process with an untried approach and the accompanying
unintended consequences, you could run a test, see what works and what doesn’t
and then take the proper steps to implement the tested approach.

CMMI tests were intended to be small and specific and to
have a definite end. They were tasked to be well planned with well-defined
criteria for success. This program was a new and powerful tool, and as it grew,
it began to be used beyond its original intent. Rather than a testing platform it
was used, in some instances, to implement nation-wide changes to Medicare and
Medicaid, without Congressional oversight. Both the Obama administration and
the Trump administration used CMMI to make some test programs permanent, effectively
changing the health care system without Congressional approval. This was done
by making the size of the test large, so it impacted a large swath of the
nation or by having a very fast phased rollout, faster than the results of the
initial test could be effectively evaluated. They also made provider
participation mandatory to ensure large participation. All of these approaches
went way beyond the basic intent of the CMMI.

While this approach was a great way to quickly initiate
change, it avoided the checks and balances of both the judicial and legislative
branches of the government. The most egregious of these tests were opposed by
patients and providers alike and these groups were often successful in stopping
the widespread adoption of the changes, but it became evident that legislation
was needed to ensure that the constitutional checks and balances were
maintained.

Congress has acted . . . legislation has been created and introduced
in the House. The Bill, HR 5741 (IH) – Strengthening
Innovation in Medicare and Medicaid Act, (a bi-partisan effort) mandates
that certain “rules of the road” must be in place to ensure that any tests have
a defined duration and that any final changes to our health care system are put
in place with Congressional approval.

CMMI is a powerful tool that can have both good and bad
impacts on our access to quality health care. This new legislation will
establish safeguards that will ensure CMMI stays within the initial intent of
the program. It will protect both providers and patients and will allow
innovation to be implemented within the checks and balances of our government.

I will keep you apprised of its progress and urge you to
encourage your Senators and Representative to support this legislation.

Medicare
beneficiaries: listen up! The Administration is introducing a proposed rule
that would arbitrarily base the prices of American medications on prices of
drugs in foreign countries. Proponents of this proposal, known as the
International Pricing Index (IPI), claim that this type of plan would cut
costs, but the truth is, this measure could harm seniors’ access to prescription
medications and stifle medical progress and the development of improved
treatments here at home.

If IPI is enacted, seniors will likely see new restrictions in the number and variety of medication options available to them and their physicians. International reference pricing proposals – which would tie U.S. drug prices to foreign countries that heavily regulate medicine accessibility — could also force a one-size-fits-all approach on beneficiaries, worsening health outcomes by assuming every patient responds the same way to all medications. If seniors are not given a voice or a choice in matters regarding their own healthcare needs, it will be harder to do what their physician believes is most effective.

Seniors must act NOW! Tell the Administration just how harmful enacting IPI and other foreign reference pricing policies could be, both for beneficiaries’ health and for American medical progress. Click here to make your voice heard.

How we pay for our health care is a mystery to most of us. We get our Medicare and insurance bills and they are hard to decipher. We pay money for premiums and when we go to the doctor, the hospital and buy are medicines, but the reason things cost what they do is often a mystery. When we hear the politicians talk about changes to Medicare, they use words and descriptions that are often unfamiliar. What we do know is that when Medicare is changed it often affects us directly, either by access to care or cost. My goal with this blog is to try, and I emphasize TRY, to simplify how the different players in our health care system interact and the forces that influence how they operate. I will also seek to explain the different tools that are used and how each one of them affect your health care access and your cost. My goal is to help you become a more knowledgeable constituent, one that understands your health care today and the ramifications of possible future changes.

I realize this is a long blog, believe me it could have been many times longer. My hope is that this blog gives us a base of understanding, a reference place, that we can use when we get into a detailed discussion concerning possible regulatory and legislative changes.

There are four major players in how we receive our Medicare health care benefits:

All of them have regulations, legislation, costs and competitive forces that affect them.

Patients – • Many of you have seen out-of-pocket costs go up while access to care has become more complicated.

Providers – • Doctors are inundated with regulations that require ever expanding administrative costs and require them to spend more and more time on non-patient contact tasks. Malpractice insurance costs continue to rise which encourages them to protect themselves by ordering more tests, procedures and specialist appointments. • Hospitals have huge fixed costs and are required to treat the uninsured. • Drug manufacturers face the risk and cost of research and development that has raised the cost of developing a new drug to two billion dollars. They are faced with required discounts on drugs while paying ever increasing rebates to insurance companies and PBMs.

Payers – • The government has seen health care prices rise while the population lives longer, drawing on a fund that is dwindling each year. • Insurance companies must keep premiums low to compete, but costs continue to spiral up. • Patients, especially the sicker ones, are saddled with paying a higher percentage of their health care costs.

Middlemen – • Pharmacies are squeezed with paying after the sale rebates and providing a myriad of uncompensated services. • PBMs are faced with a changing business model that may impact their relevance.

This is certainly a complicated business; it is a balance of the free market with a highly regulated environment. It is convoluted and, in many places, inefficient, but it is where we are today.

As the players work to improve our health care, they have tools that they use to offer choices, control costs and direct access. My goal in the explanations below is to define how these tools operate and, more importantly, how their use will impact you, either in access to care or cost.

Deductible – The patient is responsible for 100% of health care costs until this amount is reached. It is used to control unnecessary health care usage. It is a big out-of-pocket expense for patients and should be considered as health care plan choices are made.

Co-pay – An amount the patient pays each time they use a product or service. Payers use this to give the patient some cost to pay to help limit unnecessary usage. It operates a little like a deductible and adds to a patient’s out-of-pocket costs. Co-pays are often higher when seeing a specialist.

Co-insurance – Unlike a co-pay, co-insurance is not a set amount, it is a percentage of the cost of the product or service. This tool can have a big impact on a patient’s costs and its use by insurance companies has increased over the last few years. For instance, there is co-insurance in Medicare’s prescription drug benefit, Part D. If your out-of-pocket costs in 2020 exceed $6,350 dollars you are only responsible for 5% of the cost of the drug. 5% may sound small but with some of the costs of medicines today it could be a large amount. For instance, if you are taking a drug that costs $10,000 a month your out-of-pocket costs for the year would be $8,187. You would reach your $6,350 very quickly and would pay 5% of the drug’s list price after that ($500 a month). That is a lot different than paying a $3.00 co-pay once a month. By the way, the $6,350 maximum out-of-pocket in 2020 increased $1,250 dollars from 2019 rather than the approximately $100 a year increase in the years prior. This happened because of legislation that accompanied Obama care. Many senior advocacy groups fought this unwarranted increase.

Out-of-pocket maximum – Many of you are acquainted with out-of-pocket maximums, it is almost a universal benefit in private insurance. Medicare DOESN’T have an out-of-pocket maximum. Many supplemental and Medicare Advantage plans do, however, offer an out-of-pocket maximum. The Part D drug benefit also doesn’t have an out-of-pocket maximum. This is an area that many people say needs to be changed. We’ll no doubt talk more about this in later blogs.

Prescription Drugs

The following tools are used primarily in the use of prescription drugs that are covered under Medicare Part D and Part B. Part B drugs are usually injected at a doctor’s office or at the hospital.

Step Therapy – This treatment requirement is used by insurance companies to ensure that a doctor has tried the least costly medicine or procedure before prescribing a more expensive solution. This usually applies to medicines and is also called fail first, meaning the medicine must not work on the cheaper option before the more expensive option is tried. This treatment regulation is also used to negotiate with drug manufacturers to lower their price so they can be the medicine first tried in the step therapy requirement. This approach raises a barrier to timely access when the doctor, who knows a patient will not respond to the cheaper medicine must still delay the treatment that works while the patient fails on the first medicine. Another access barrier occurs when a patient changes insurance companies and must repeat the step therapy/fail first protocol before they get access to the medicine that had preciously proven to work for them. It is also important to mention that doctors sometimes receive payments for using specific, often expensive, medicines. This is one tool the insurance companies use to control costs.

Drug tiers – This tool puts different medicines in different tiers or categories, historically 3 or 4 but the number of tiers seems to be increasing. These tiers usually go from least expensive to more expensive, with increasing amounts of patient co-pay or co-insurance as the tier gets higher. It is a way to encourage a patient to use the least costly medicine. It also is used to negotiate with drug manufacturers to lower the cost to the insurance company for inclusion on a lower, i.e. higher usage, tier. Identifying which tier your medicine is in can make a huge difference in your out-of-pocket costs.

Importation – There is a disconnect between the price of drugs in America and the price of drugs in some other countries. This is one of the most complicated areas of health care. Some have proposed importing drugs from Canada. Some states have even passed legislation to allow the importation of medicines. There are safety issues and supply issues involved with this approach. Canada itself has said it couldn’t authorize, support or guarantee the safety of drug importation into the U.S. This is a tough issue that will take some big changes to rectify. This is another area we will pursue in later blogs.

International Reference Pricing – This government authored approach seeks to solve the problem described in importation of other countries paying less for medicines. It uses drug prices from some selected countries to set the maximum price for those drugs in America. This solution, which seems simple, is fraught with many questions and problems. We will delve into those questions and problems in a later blog.

Non-interference/government negotiations – This part of the initial Part D legislation left the negotiations of drug prices to the forces of the free market. While it seems like allowing the government to use its force of the millions of Medicare beneficiaries to negotiate lower prices would be beneficial, it isn’t supported by studies and projections. The main barrier is the need to restrict the formulary (the list of drugs available under Part D) to generate any leverage on drug prices. It would be a recipe for access restrictions for life saving medicines. This is another area for future discussion on this blog.

These are just a few of the tools and just scratches the surface of the complexities of our health care system. Hopefully it will give us a base for better understanding any proposed changes in the regulations and legislation that govern Medicare.

Happy
Holidays! I hope everyone’s preparations for family and friends this holiday
season is going well. There’s a lot of things going on this time of year to
keep us all busy. As I mentioned in my last blog, one of the most
important year end tasks is reviewing your Medicare insurance coverage,
including your Part D prescription drug plan. Because I moved to a
different state it was especially important that I reviewed my coverage and in
doing so I had some interesting experiences and some money saving
discoveries. I think by going through some of the decisions and tradeoffs
I had to make, they might help us all better understand the policies and
regulations that are in place now or how the changes that are being considered
by our leaders in Washington might affect each one of us.

As I
mentioned I moved to a different state and that move gave me some broader
choices. Previously, I had a supplemental insurance plan and a
stand-alone Part D plan. The availability of Medicare Advantage plans in
my old state were limited so a supplemental plan was the best choice for my
wife and myself. In my new state I had the choice of various Medicare
supplemental plans, but I also had the choice of five different Medicare
Advantage plans. Since the premiums are often less or zero with Medicare
Advantage, I was very interested in what these five plans had to offer.
Here are just a few things that I had to consider when looking at the Medicare
Advantage plans offered in my state:

Were my new doctors in the PPOs?

What doctors were part of the HMOs?

What would my new premiums be?

What were the copays for an office visit to my primary care doctor?

What were the copays for an office visit to specialists?

What was the copay for a visit to the emergency room?

Did the plan include Part D, if so, did it cover the prescription drugs that we currently use?

What were the copays on the medication?

Was any medication on specialty tiers?

Was coinsurance part of the plan, if so, what was the percentage?

What was the yearly out-of-pocket maximum for health services?

Did the plan include dental, hearing, eyesight or other benefits (like silver sneakers)?

There was a
lot to consider and a lot of acronyms and terms that I had to understand.
It was no small task and took considerable time. It was a little easier
given I’ve been involved in health care policy for over 20 years, but it was
still time consuming and arduous at times. After I had made my
preliminary decision, I used another resource that was available to me as a
military veteran. When I first joined the Air Force, I had the
opportunity to use USAA for my car insurance. I’ve gone on to use them
for other insurance and financial needs and they offer a phone number and
assistance for choosing insurance plans. I’m not selling USAA products, I
don’t sell anything on this blog, but I want to remind you that you should
research all the resources available to you and take advantage of any help
available. I did and was very pleased with the help and advice I got from
the USAA person.

In the end I
chose a Medicare Advantage PPO plan and found that I saved a large amount of
money on premiums. I had to balance that with an increase in my yearly
out-of-pocket maximum and some higher copays. I’ll have to see what kind
of care I receive, but on balance I think I will be better off.

I hope you
are satisfied with your insurance or made a change during this open enrollment
period that will give you better benefits or cost less. As I’ve said
before this blog will focus on you, the consumer and the impact that
regulations and legislation will have on your access and cost. Health
care is complicated, you probably had that driven home as you reviewed your
coverage. I will work to try to simplify the Washington rhetoric and boil
things down to show how their proposals and solutions will affect you.
As part of this
endeavor my next blog will define some of the terms that are used in health
care insurance, regulations and legislation. My definitions will focus on
how these different items affect you and your level of care or
pocketbook. Ever wonder what the difference is between copay and
coinsurance? Watch for my next blog, that will strive to demystify this
complicated thing we call health care.